In order to develop more work-life benefits in our workplace, we want to survey employees to determine their child care concerns. This information will be used to develop a business strategy that meets the needs of our employees. We would like the information you provide here to be anonymous, so please do not sign your name on the survey. Developing an effective strategy depends on obtaining a true snapshot of your child care concerns. Please be honest in your answers.

1. First, we would like to know the ages of the children living in your household.Write in the number of children in each age category.# of children ages__________a. birth - 18 months__________b. 18 months - 3 years__________c. 3 years through kindergarten__________d. 1st grade through 3rd grade__________e. 4th grade through 6th grade

If you have no children living at home or none in the above age categories, please indicate none and return the survey.

2. Do any of your children in care have special needs?a. Yes (please explain) __________________________________________________________________________________________________________________________________________________________________________

b. No

3. In the next section please list the age for each child that you currently have in child care. Please circle (a) the type or types of care that each child is in (if you have more than five children please provide this information for your youngest five) and (b) the times when child care is needed.

4. Did you get all the child care you needed during the last 12 months? Check the best response._____a. Yes, I got all the care I needed. (Skip to question 6.)_____b. I got some of the care I needed._____c. No, I did not get any of the care I needed.

5. If you couldn’t get all the child care you needed, please indicate the reason. Check all the reasons that fit your situation._____a. Cost of care was too expensive._____b. Couldn’t find anyone to care for my children. (Comment)_______________________________________________________c. Care was too far away._____d. Care wasn’t available when I needed it. (Comment) ______________________________________________________e. My child has special needs that couldn’t be accommodated. (Comment)______________________________________________________f. Other: ____________________________________________________If you have only school-age children who stay home alone before and after school, please skip to question 16.

6. Please indicate the age of your children, the average number of hours of child care received and weekly costs.

Age Hours per week Weekly cost

7. Do the total costs of child care create a hardship for your family? Check the best response._____a. Extreme_____b. Moderate_____c. Mild_____d. None

8. Do you have backup child care when your regular care is unavailable? Check the best response._____a. Always (go to question 10)_____b. Usually_____c. Sometimes_____d. Never

9. In the last 12 months, what are the reasons your regular child care has been unavailable? Check all that apply._____a. Child sick_____b. Family provider unable to provide care_____c. Relative unable to provide care_____d. School closure_____e. Bad weather; unable to take child to provider_____f. Other (comment) ____________________________________________________

10. Who cares for your child(ren) when your regular child care arrangements are unavailable? Check all that apply._____a. Spouse who doesn’t work outside the home._____b. Spouse stays home from work with child._____c. I stay home from work to be with child.

To do this I have to make the following arrangements. Check all that apply._____ sick leave_____ vacation day_____ personal leave_____ unpaid leave_____ Alternative child care arrangements._____ Child cares for self._____Other (comment) _____________________________________________________

11. Do you participate in making child care arrangements in your family?_____a. Yes_____b. No

12. Who takes or drives your child(ren) to and from child care? Check all that apply._____a. Care is in our home. Skip to question 15._____b. I do_____c. Partner_____d. Other: __________________________________________

13. What impact has problems with child care had on your household? Check all that apply.One or more of us have had to:_____a. Limit work hours_____b. Take time off from work_____c. Quit a job

14. How much do you worry about your child(ren) in child care while at work? Check the best answer._____a. I don’t worry at all. I have great confidence in the care they receive._____b. I am fairly confident in their care. Every once in a while I have some concern._____c. I occasionally worry._____d. I worry often and have some doubts about their care._____e. I am extremely worried and am apprehensive about their care.

15. How much do you worry about your child(ren) who are at home alone before or after school? Check the most appropriate answer._____a. Question does not apply to me._____b. I don’t worry at all. I know they are safe and happy._____c. I am fairly confident that they are safe and happy._____d. I occasionally worry about them._____e. I worry often about them and have doubts about their safety._____f. I am extremely worried and am apprehensive about their safety and well-being.

16. When you need to be away from work for a short time for a child’s appointment or a child care emergency, how does your supervisor manage your absence? Check all that apply._____a. Allows personal leave time._____b. Allows me to make up lost time._____c. Reduces wages for missing time._____d. Demerit or mark against work record._____e. Other (comment) ___________________________________________________________________

19. Sometimes, child care arrangements affect parents at work. During the past six months, have you had difficulties related to child care in any of the following areas? Please circle the appropriate answer or (N/A).

No Minor problem Major problemAbility to concentrate on work Disruption of your work Arriving to work on time Stay late (as needed) Traveling for the job Leaving work early or staying home to care for a sick child

20. During the past six months, how many days have you left early or arrived late because of child care difficulties? (Please provide your best estimate) _____ Days

21. During the past six months, how many days have you been absent from work because of child care difficulties? (Please provide your best estimate)_____ Days

22. How many years have you worked with this company? If a new employee insert “0.”_____ Years_____ Months (approximate)

23. What is your work schedule? Working hours Total hours per week Days of the weekFull-time __________ __________ __________Part-time __________ __________ __________ Other __________ __________ __________